The Many Faces of the Electronic Health Record

Electronic health records are catching on. Adoption rates are climbing, and there are more products, more articles, more seminars, more complaints, and more debates. Do EHR systems save money? Do they improve care? Do they lower productivity? Are they difficult to use? Do they make the patient narrative harder to create and follow? Many discussions seem to be at cross-purposes because those involved are talking about different things but using the same or similar terms. When one takes a closer look, it is obvious that everyone is talking about their idea of what an EHR system should be, which increases rancor without providing clear guidance for future system designs.

Much of the problem stems from the fact that the definition of the electronic health record doesn’t do justice to what an electronic health record system is expected to do. The electronic health record, like the computer-based paper record before it, is a concept awaiting realization in the real world. Here is the official definition of the electronic health record as it appears in the 2009 ARRA bill that contains the HITECH Act:

ELECTRONIC HEALTH RECORD —The term ‘‘electronic health record’’ means an electronic record of health-related information on an individual that is created, gathered, managed, and consulted by authorized health care clinicians and staff. (123 STAT. 259)

This is a bare-bones definition. However, it conveys the basic nature of the electronic health as envisioned by those writing the legislation; namely, that it is a store or archive of information about a patient.

An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care. EHRs can:

Allow access to evidence-based tools that providers can use to make decisions about a patient’s care

Automate and streamline provider workflow

One of the key features of an EHR is that health information can be created and managed by authorized providers in a digital format capable of being shared with other providers across more than one health care organization. EHRs are built to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.

This definition adds more flesh to the original while retaining the idea that an EHR system is just an electronic chart. Such thinking impedes discussion about EHR effects and EHR design because it vastly oversimplifies what is actually expected of modern EHR systems. Yes, an electronic record should provide access to a patient’s information, but an electronic health record system that does only that would be considered a colossal waste of time. (Come to think about it, systems that purport to do more are also frequently considered to be a colossal waste of time.) In the era of MU, EHR systems are expected to be far more involved in patient care than paper charts ever were. Today, EHR systems are expected to be computing/collaboration/data exchange/workflow systems—exceeding, by far, what was expected of paper.

The modern EHR is a concept–more of a wish, really–awaiting fulfillment, and it is very much a work in progress. The expectations placed on modern EHR systems account for the difficulty in designing and building them. These expectations also account for the all-over-the-map nature of EHR-related discussions and research reports. Meeting expectations requires EHR systems that are comprised of a confederation of capabilities. Unfortunately, these capabilities have significant intrinsic complexity, making them a challenge to design, build, and integrate. Each of the major aspects of EHR systems–usability, workflow, security, safety, data exchange, storage, reporting and secondary data use, and collaboration capability—has its own researchers, proponents and detractors. All are talking about EHR systems, but each group is using its own terms and concepts. Progress requires that everyone be on the same page with a shared conception of what is to be built. And, of course, building a modern EHR means addressing all required capabilities. The problem is that no one knows the best way or ways to pull this off.

So where does this leave us? Unfortunately, we are in an assortment of groups without a set of unifying concepts that can bridge the divisions (see Mathematics and Clinical Concepts, Part I: The Need for Formal Methods and Theories). There are usability people, workflow people, safety gurus, security experts, database specialists, implementation leaders and others who are working to solve one part of a very difficult problem. However, without unifying theories or concepts, each group unwittingly takes on the role of the blindfolded searcher with his/her hands on a single part of the proverbial elephant.

The paucity of published research on EHR design and architecture is troubling and curious, given the amount of discussion EHR systems incite. I search the literature monthly, using PubMed, IEEE Xplore and the ACM Digital library, and there is only a trickle of research that could be used to guide design decisions. EHR design/architecture research occurs predominantly in private companies and is product-focused. Most EHR research seems to focus on the impact of the technology (cost, clinical outcomes, usability, etc.). No doubt, this research is important; however, without research on fundamental EHR structures, significant system improvements are unlikely.

Basic research is needed on algorithm design, security protocols, user interfaces, data structures, data models, process support—all the things needed to enable the functionality everyone is expecting EHR systems to provide. This is not to say that no quality public research is being done. The Strategic Health IT Advanced Research Projects program is funding good research, and indeed, we need more research initiatives that focus on the fundamental properties of clinical systems.

EHR systems began years ago as front-ends to collections of patient information. Now, they are expected to do much more than act merely as a chart or record. The complaints and debates that are now evident are the result of the ongoing clash between expectations and reality. Progress requires that research and public discourse move beyond the idea of EHR systems as digital charts and instead see them for what they becoming–complex care support systems that are worthy of scientific study.

“Modern electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care.
EHRs can contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results. It also allows access to evidence-based tools that providers can use to make decisions about a patient’s care. It helps to automate and streamline provider workflow.
One of the key features of an EHR is that health information can be created and managed by authorized providers in a digital format capable of being shared with other providers across more than one health care organization. EHRs are built to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.”